Executive Summary

Since Sudanese protesters took to the streets in December 2018 to demonstrate against government corruption, economic mismanagement, and brutal repression, forces loyal to the government of President Omar al-Bashir have carried out massive violations of human rights. Peaceful protesters have been attacked by government security forces using disproportionate, unnecessary, and sometimes lethal force.[1] They have been arrested and detained without charges and denied access to their families or medical care. Government security forces and police have prevented medical personnel from attending to the wounded and, in many cases, have arrested and detained these personnel, conducted incursions and attacks inside medical facilities, and targeted, injured, and even killed health workers while they have been carrying out their medical duties or participating in the protest movement.[2]

To date, police and National Intelligence and Security Services forces have entered and conducted attacks on at least seven medical facilities, arrested at least 136 health personnel, fired teargas and other weapons into hospital wards, and closed access to medical care for patients.[3][4][5] At the time of publication, 60 protesters had been killed by government forces (one was a practicing doctor and two were medical students). Virtually all of these violations are explicitly prohibited by international law and by Sudanese national law. These incidents also have long-lasting impacts on health[6]: tear gas and rubber bullets have significant medical impacts and can cause permanent disability and even death; live ammunition utilized on this massive scale against crowds causes many injuries in addition to the deaths already reported, and the severe reduction in health care capacity from attacking hospitals and detaining and torturing doctors undermines the already strained Sudanese health care system.

By reviewing and confirming reliable on-the-ground reporting from contacts in Sudan and employing open-source investigation methodologies for verification, this report details these attacks. Based on the available information, Physicians for Human Rights (PHR) finds that the government of Sudan has used unnecessary and disproportionate force against its citizens, illegally attacked medical responders and facilities, and tortured detainees. This campaign of intimidation and persecution violates both national and international laws and interferes with basic norms of medical ethics and care for the wounded and sick. PHR calls on the government of Sudan to immediately cease attacks on medical personnel, release detainees being held without charge or trial for exercising their fundamental rights and ethical obligations, ensure basic protections for medical facilities, seek accountability for members of the government and security forces who have perpetrated these crimes, and demand justice for the victims. Additionally, PHR calls on UN member states, regional bodies, and the international medical community to press the government of Sudan to stop the violent suppression of dissent, to respect the ethical obligations of doctors and the sanctity of health facilities, and to hold the government of Sudan accountable for its human rights violations.

Background

Sudan has experienced an unprecedented series of social protests since December 19, 2018. In response to a chronically corrupt and repressive government and most recently triggered by rapidly rising food and fuel costs as well as the removal of subsidies for vital resources, tens of thousands of students, professionals, religious and community leaders, and workers across many fields have participated in largely peaceful marches and rallies.[7][8][9][10]Of note, it has been a deliberate decision of the movement to ensure that the protests are peaceful. Protesters have demanded better economic conditions and control of corruption and have called for the president of Sudan, Omar Hassan al-Bashir, to step down after 30 years of oppressive rule.[11] According to recent reports, the government has responded by shutting down social media access, closing newspaper offices, arresting and imprisoning scores of people, and attacking and killing more than 60 protesters.[12][13] On February 22, 2019, President al-Bashir announced a state of emergency, effectively dissolving federal and state governments and replacing civilian leadership with military leaders in an effort to end protests and regain authority.[14][15]

Physicians and other medical personnel have played an important role, speaking out in support of the rights of protesters and caring for the wounded.[2][16][17] Two of the leading medical associations in Sudan (Central Committee of Sudan Doctors and Sudan Doctors’ Syndicate) have joined together to form a consolidated office (along with the Consultants and Specialists Committee), which has taken a leading role in demanding change, bearing witness to the violence, and providing medical care.[18] Doctors have also been a part of the Sudanese Professionals Association to empower professionals who engage in the protests and calls for reform.[19][20]

News reports and direct communications note that medical personnel have been prevented from attending to the wounded and, in many cases, have been arrested and detained, or attacked inside medical facilities[17][18] and targeted for carrying out their duties.[2] National Intelligence and Security Services forces have entered medical facilities, arrested health professionals, fired tear gas and other weapons into hospital wards, and closed access to medical care for citizens.[3][4][5] Virtually all of these violations are explicitly prohibited by international law and by Sudanese national law.

Physicians for Human Rights (PHR) is working with our Sudanese colleagues to bring attention to the egregious violations of human rights of protesters in general, and the specific targeting of health care. PHR is deeply concerned that the government’s actions are having dramatic negative impacts on health, both in the short and long term.

This report addresses Sudan’s use of unnecessary and disproportionate force that endangers the health of peaceful protesters and the targeted attacks on health personnel who play an essential role in civil society.

Methodology

Physicians for Human Rights (PHR) sought to triangulate eyewitness accounts of attacks with reports from other witnesses, news reports and video footage, legal records, medical documentation, and other sources to produce sufficient data to make assessments. Data was compiled from direct communications with Sudanese medical organizations and their members as well as open-source videos and images. Direct communications with Sudanese physicians as well as expatriate Sudanese physicians living in North America included interviews of physicians who had participated in protests or cared for injured activists. In cases where physicians were injured or abused by government officials, PHR researchers attempted to obtain and analyze any available medical records to corroborate their reports.

Human Subjects Protections

Interviews were conducted using a range of security precautions and protections. For all interviews, the PHR team obtained informed oral consent from each interview subject following a detailed explanation of PHR, the purpose of the investigation, and the potential benefits and risks of participation. PHR researchers did not record subjects’ names, nor did they make audio or video recordings of these interviews. Participants could stop the interview at any time or refuse to answer any questions. Interviews were conducted in the language preferred by the respondent.

Interview methods were reviewed and exempted by the Ethical Review Board (ERB) at PHR based on Title 45 CFR Part 46 provisions, which are used by academic Institutional Review Boards.[21] All of PHR’s research and investigations involving human subjects must be reviewed by the ERB and conducted in accordance with the Declaration of Helsinki as revised in 2013.[22]

Limitations

Given that this data was primarily collected through secondary sources on an urgent basis in a volatile context, there are limitations in duration, scope, and access. The study covers events between December 19, 2018 and March 17, 2019. The scope of the investigation focuses on human rights violations of protesters and medical personnel. PHR’s analysis is based on data that was safely obtainable from Sudanese health professional colleagues and from open sources. The forced closure of newspapers, shutdown of social media channels, and limitation of access to information have significantly affected the availability of information on the protests, living conditions, and arrest details of the detained. Virtual private networks, however, have allowed citizens to share information. Notwithstanding these limitations, the evidence available and the trends noted have produced sufficient data to make informed conclusions and recommendations about alleged reports of human rights violations during the recent protests in Sudan.

Findings

Findings in this report focus on: reports of the use of disproportionate and/or unnecessary force; attacks on medical facilities; violations against medical personnel; and evidence of torture and abuse of activists as well as medical personnel.

Disproportionate and/or Unnecessary Use of Force in Protests

There are multiple reports of unnecessary, disproportionate, and improper use of force during the recent protests against peaceful and unarmed Sudanese protesters. This report highlights: information gathered from open sources; information gathered from protesters; and injuries from unnecessary and disproportionate use of force.

It is important to note that tear gas, rubber bullets, and other crowd-control weapons pose particular health risks to those with underlying medical conditions and may cause death in some cases.[6][23][24][25] Live ammunition can cause severe injuries to all body systems, in addition to death. Our findings also note the use of shotguns with solid metal pellets that project in an array. These weapons are particularly dangerous when used against crowds, where many people, including unintended targets and bystanders, can be hit simultaneously. Most international regulations [41] ban the use of live ammunition, shotguns, and metal-composition projectiles in these contexts.

Information Gathered from Open Sources

Physicians for Human Rights (PHR) researchers reviewed more than 50 videos and images of protests in several cities in Sudan to evaluate claims of attacks and corroborated this information with interviews with Sudanese physicians. These were just a fraction of the open-source media available online to illustrate the massive scale of human rights violations. Our open-source investigation team was able to collect media found in publicly available online resources, confirm the geographic location and time and date data, and verify them. These images were categorized as definite confirmations (multiple established sources, clear images, metadata available), probable confirmations (with fewer or less established sources or less clear images but still containing valuable data), or unconfirmed (initial or unestablished sources or unclear images). Based on the confirmed data, PHR identified the following incidents of serious concern:

Sudanese security and police deployed unnecessary, indiscriminate, and disproportionate force to repress protests and violate freedoms of assembly and speech.

Government security forces used weapons not appropriate for crowd control of peaceful protests, such as live ammunition and lead shot, and used lethal force on unarmed civilian protesters without cause.

Uniformed and plain-clothed National Intelligence and Security Services (NISS) forces pulled civilians out of their homes in Khartoum, and beat many people with batons, dragging them to vans.

In districts of the greater Khartoum urban area such as Omdurman and al-Souq al-Arabi, security forces used tear gas and stun grenades. On an almost daily basis, they also simultaneously fired into crowds of protesters without any previous indication of violence or threats to public order and without any prior warning.

Uniformed and plain-clothed NISS forces fired live ammunition at protesters in the al-Souq al-Arabi, Nasir Extension, and Burri al-Daraisa districts of Khartoum.

Multiple images and videos show that this violent suppression of dissent inflicted traumatic injuries on protesters. These injuries include a man with extensive linear contusions and bruising on his back consistent with being beaten with a stick or baton and others with facial and body trauma consistent with shotgun injuries and contusions and burns on their face and arms from tear gas canisters.

The following case examples list open-source data that PHR used to triangulate initial reports of unnecessary and disproportionate use of force during protests.

Both images and videos shared and verified on Twitter depict the tear gassing of peaceful protesters at the National University of Sudan. Footage and images, from a multitude of angles, show students chanting before tear gas appears into the frame, engulfing the students in smoke as they run away. Students are shown covering their mouths with their hands and coughing as they flee the area. The before and afterimages in the media show the use of tear gas directly toward and against peaceful protesters, constituting an unnecessary and disproportionate use of force by police and state security forces.

This graphic footage, shared on Twitter, shows the brutal beatings and detention of protesters outside their homes in the Shambat district of Khartoum. This video illustrates the excessive use of force by President Bashir’s security and police forces.

Information Gathered from Protesters

One witness told PHR of the terror he felt when NISS forces attacked a peaceful protest in Khartoum in which he was taking part. “On December 25, a central protest was taking place downtown…. When the NISS started firing tear gas, about 800 of us divided off and went off on a different route. NISS was chasing us with live fire into the air. We had to go into a parking structure with one big door. Then, the armed forces started firing tear gas inside. We had to jump between different houses and buildings to get away. I and two other protesters ended up in a small hotel. We found six other protesters already there. The total ended up being 15. Then we heard the armed forces following us. I and another person had to hide under a bed. Then, we heard that the rest were arrested. They were shouting at us and arresting the rest.”

Another noted that the use of tear gas is frequent: “In the seven protests that I’ve attended, I’ve felt tear gas in every one of the seven. When we get just tear gas, we just are thankful that it wasn’t something else. That is a lucky day.”

One witness said: “I myself that day saw many, many, many situation of violence. We [were] hit multiple times by tear gas and stun guns…. A lot of tear gas. Heavy tear gas. They may even shoot it inside the building. Just everywhere. Inside the building, inside the house, you don’t know where it will land.”

The witnesses also noted that live ammunition and shotguns were being used more often in the early weeks of the protests. “Now, they are just shooting live ammunition into the air. I didn’t see a lot of injured protesters as much in the past month. Different tactics are being used.” Another witness confirmed that “Since mid-January, you haven’t really heard live ammunition. But, I have experienced tear gas in every single protest I have participated in.” Regarding new tactics, the witness noted that “At first, they use tear gas during a live gathering even when it was peaceful. We made a decision to be very careful to be peaceful. After that, they go to the gathering points that are announced before. They even start firing tear gas before the gathering gets started. If the protest is scheduled at 1 p.m., they will start firing tear gas in that area at 12:45 just to prevent it.”

Injuries from Unnecessary and Disproportionate Use of Force

“He was shot by live ammunition and was immediately unconscious. I saw this patient. The bullet was in his brain through his eye.”

A Sudanese doctor who attended to a student killed during protests

Interviews conducted by PHR with Sudanese physicians confirm the use of unnecessary and disproportionate force by government security forces. One witness recalls that he saw 15 patients in one day. “The majority of the cases were live ammunition – five to six – then four to five [cases] of rubber bullets and a few tear gas cases.… One protester was shot by a bullet which caused a pneumothorax (collapsed lung). But we believe that was a rubber bullet. There was another case that they shot a [shotgun]. When they wanted to examine the patient, he had multiple shots all over his body that were bleeding. They penetrated. The rubber bullets mostly caused some superficial wounds but the shotgun wounds, they would penetrate deep.”

On January 17, 2019, an electrical engineering student named El Fatih Omer was killed during the protests. He was participating in the protests when he was shot in the eye and was brought, unconscious, to a makeshift clinic. The doctors who received him assessed that the bullet was life threatening and immediately took him to a hospital where he survived for four days before dying. A witness confirmed to PHR that Omer was killed by live ammunition: “He was shot by live ammunition and was immediately unconscious. I saw this patient. The bullet was in his brain through his eye.”

A second doctor interviewed by PHR had attempted to attend Omer’s funeral at his home. This witness recalled that “after his death, we went to his family’s house. They fired tear gas into the family’s house in Omdurman when we gathered in his house. There were a lot of people, maybe 400-500, not all of them are protesters. It is just a culture in Sudan that family and neighbors and relatives gather. They were not all protesters. They fired tear gas into us. It was peaceful. We all ran into the neighbor’s houses. I felt the tear gas that day.”

Based on PHR’s interviews, there are also many highly credible reports of tear gas canisters being aimed directly at protesters, and reports of many wounds caused not by bullets (rubber of otherwise) but by the metal tear gas canisters themselves.

“They hit me in over 100 spots.”

PHR interviewed one witness who was beaten during a protest and sustained a debilitating hand fracture. He described that during one of the protests in which he was peacefully protesting, National Intelligence and Security Services (NISS) forces came and started firing tear gas into a crowd. The group of protesters that he was with then dispersed and went in different directions. He was running with a small group of about 10 people when a woman next to him tripped and fell. He instinctively stopped to help her up when he was caught by the NISS.

He recalled that “then they caught up to me and began beating me viciously. They were using hoses, black hoses, to beat me that were coated in the inside with a hard material. At first, they hit me in the head, which caused me to fall directly on the floor and so I got cut and bled. Five people ganged up on me. These five are said to be the police for crowd control but they themselves are from the NISS. They were beating me severely and I begged them to stop. One officer began to reprimand me strongly. He told one of the others to grab me and make sure that I didn’t get away and then they took me to their Toyota car. When I got there, there were three other cars each with seven to eight people who are wearing different uniforms but spoke to each other in the same way, and they seemed to be familiar with each other and they followed the same directions.

As soon as they saw me being taken by the others they said ‘Oh, I see you guys got this guy’ as if they just trapped a new catch. They also began to beat me and shout to get in the truck quickly. They then took me to the spot where they keep the captured. They hit me in over 100 spots.… One remarked that he should cut off my legs so that I knew not to go to the protests again. After that when they make you get in the car, they tell you to put your head down, so you don’t see where we are going. They also told me to close my eyes, they took me to this place, when I arrived … it took about a quarter of an hour … I didn’t know where they took me exactly, but I knew it was a national security building. When I arrived, I had many cuts and was bleeding heavily. I was released many hours later and went to the hospital, where I found that my XXXX [redacted for security] was broken.”

PHR forensic experts have reviewed this witness’s medical files, including X-rays, and confirm the injuries he described – which are consistent with his report of being beaten with blunt objects – and that he has sustained debilitating fractures consistent with the manner that he reported.

Attacks on Medical Facilities

PHR has collected data on attacks on medical facilities during and after protests based on reports from Sudanese medical colleagues and corroborated with open-source data. Attacks on medical facilities impose critical health risks in both the long and short term. Tear gas and other chemicals can contaminate the hospital environment, especially injuring those with existing illnesses and injuries. Exposure to tear gas in closed indoor environments extends exposure time and dose, exacerbating their effects, particularly on people who are not able to walk and/or escape. These chemicals also pose longer-term health risks for patients and medical personnel that work or are being cared for in these contaminated spaces. In the long term, attacks on facilities can erode trust in the health system and intimidate people from accessing necessary health services. PHR’s previous research into crowd-control weapons and their health impacts[6] illustrates that, far from being benign, these weapons impose heavy short- and long-term burdens on patients, health workers, and the health system as a whole.

PHR has identified at least seven incidents that support allegations of multiple intentional attacks on Sudanese medical facilities:

Omdurman Hospital (January 9, 2019)Multiple verified and geolocated videos and images from various individuals illustrate that uniformed NISS forces entered hospital premises, shooting from rifles into the hospital and then entering the facility. They fired tear gas and other weapons into medical wards and then stood outside and arrested medical personnel that evacuated the building. The videos show that at least one ward of the hospital was filled with tear gas, causing chaos as personnel tried to open windows, release oxygen tanks to dilute the gas, and evacuate patients.

Al-Arbaeen Specialized Hospital (January 9, 2019)Although the exact sequence of events is unclear from the media provided, videos show that glass doors and windows facing steps (presumably the entrance to the hospital) were broken, with glass shattered in the entrance way. Security forces were not visible in the videos. Patients and families were evacuated in the aftermath of the attack and some appear to be suffering from tear gas effects (tearing of the eyes and redness and inflammation of the skin).

Bahri Hospital (January 13, 2019)Sources reported that the hospital was attacked on January 13. No other data was available at the time of this report.

Madani General Hospital (January 13, 2019)Sources reported that the hospital was attacked. No other details were available at the time of this report.

Al-Faisal Hospital (January 17, 2019)Sources reported that NISS forces entered the hospital and fired tear gas. At least one doctor was arrested and taken away.

Haj al-Safi Hospital (January 2019, exact date unverified) Sources describe NISS forces firing tear gas and ammunition inside the Haj al-Safi Hospital. One report notes that plain-clothes officers are stationed inside the hospital. This incident was also reported by the United Nations Office of the High Commissioner for Human Rights.

“I know that if a doctor gets arrested, they will be detained for a long time. I’m afraid of being a doctor in Sudan. We are all afraid.”

A Sudanese doctor

Violations Against Medical Personnel

PHR has communicated with colleagues in Sudan and elsewhere to compile accounts of the targeting of medical personnel and to detail incidents of their arrests and/or detentions since the beginning of the protests. Some, but not all, of these medical professionals were noted to have been involved in the care of protesters, to have made statements supporting the protest movement, or simply to have participated in protests along with other professionals and community members. Based on communication with local sources, at least 136 physicians have been arrested and detained. Doctors were arrested while participating in protests, while working in hospitals or clinics, and in their homes.

Interviews with Sudanese physicians noted that doctors are being directly and intentionally targeted by government forces as a form of intimidation because “they hate us so much. They blame us for the revolution.” Another doctor stated that he takes explicit measures to avoid being targeted as a physician: “It is important that when attending the protest you leave your identification papers or documents far away and even your phone.” A third doctor stressed the point that “I just know that being arrested as a doctor, you will be treated very differently from others…. They do not release doctors. We are more exposed to violence and assault…. This regime believes that doctors have a major role in leading the protests.” Another reported the intimidation he feels as a result of what has happened when his medical colleagues have been targeted: “I know that if a doctor gets arrested, they will be detained for a long time. I’m afraid of being a doctor in Sudan. We are all afraid.”

Violations reported by PHR take the form of specific attacks on physicians as well as general incidents of intimidation, persecution, and violence against medical personnel.

Specific Attacks on Physicians

“They killed him for doing his job, for just helping others.”

A colleague of Dr. Babiker Abdul Hamid, who was shot in the chest and killed while attending to injured protesters

In one widely reported incident during the January 17 protests, a physician, Dr. Babiker Abdul Hamid, was killed while attending to an injured protester and urging the security forces to help the victim. Police reportedly shot the medical responder in the chest with a shotgun.[17][26][27] Dr. Babiker had helped set up an ad hoc field emergency hospital in a small school just adjacent to the protest site. While the clinicians were working, a witness told PHR that NISS members in plain clothes were shooting guns in the air and making noise outside, demanding that the doctors evacuate and bring out the injured protesters. Dr. Babiker went outside to urge the NISS to retreat, stating that those inside were injured and that the doctors were just trying to help. He was shot directly in the chest and died soon thereafter. Of note, PHR has assessed Dr. Babiker’s post-mortem records and attests that shotgun pellets were widely dispersed in his body.

The witness told PHR: “That day, I remember well, because there was a group of doctors that was helping the injured protesters. They were there without any sort of arrangements. I just found myself among other doctors that were helping. We made a makeshift clinic in a small elementary school. We had referral IV lines, normal saline, gauze, and basic supplies. We just treated what we could do. There were 10-20 people injured who were affected by live ammunition, rubber bullets, and tear gas. We would do the basic stuff and then transfer to the hospital once they were stabilized. It was very scary. The NISS were surrounding the school.” Of Dr. Babiker, the witness said: “They killed him for doing his job, for just helping others.” Another witness confirmed that “He said he was a doctor and he was shot point blank.”

Dr. Babiker went outside to urge the NISS to retreat, stating that those inside were injured and that the doctors were just trying to help. He was shot directly in the chest and died soon thereafter. PHR has assessed Dr. Babiker’s post-mortem records and attests that shotgun pellets were widely dispersed in his body.

In another case, a physician was physically assaulted by security forces in his home and suffered a broken femur (thigh bone) during his arrest. It is important to note that femur fractures require significant force and are rarely the result of accidental trauma in adults. PHR was not able to review the images as the patient is still in detention.

On March 2, 2019, Dr. Mohammed Abdulkareem Mohammed Abdulraheem, assistant professor at the al-Zaeem al-Azhari University, was sentenced to three years by the emergency courts on February 28, 2019 and moved to al-Huda prison to serve his sentence. He was convicted of disrupting public order and is the first doctor to be sentenced under state of emergency laws. He was later acquitted on appeal.

PHR has confirmed reports that on January 25, 2019, Dr. Shihabeldin Ibrahim, a general practitioner in el-Obeid, was targeted by security forces for participation in the protest movement and aiding injured protesters. NISS forces had attacked him at his own home, beaten him, and taken him to security facilities (colloquially known as the “fridge” for the exposure to very cold temperatures there as a form of torture). After repeated requests by his family, Dr. Ibrahim was allowed to be visited by his family after about 40 days in detention. According to a source interviewed by PHR, he appeared unwell and had been tortured into signing an affidavit, admitting to alleged crimes he did not commit. As of this report, he has been held in detention without any formal charges and without being guaranteed his rights to legal representation or freedom from torture and abuse.

Dr. Mohamed Naji al-Assam was the spokesperson of the Sudanese Professionals Association (SPA). He appeared in a live stream video denouncing the government and was a leader of the protest movement. He was arrested in Bahri town, where he was seeking refuge, when his apartment was raided. NISS tortured and interrogated Dr. al-Assam, seeking information about the SPA and its members. After six weeks in custody, Dr. al-Assam’s family was briefly allowed to visit him and found him psychosocially impacted and physically diminished. He remains in detention, and his family has not been able to visit him again.

On January 28, Dr. Ali Ahmed Mohamed Matar was seeking refuge in a hotel room when he was arrested by the NISS. He remains in detention. Reports from now-released detainees describe that he was tortured and forced to confess to being an atheist and communist. They describe hearing him screaming and crying for several days. He was later moved to a more secret detention facility where his lawyers and family have not been able to visit him.

PHR has identified that detainess have had urgent medical needs that are not being provided for.

One of these cases concerns Dr. Muaz Faisal, an obstetrician who was arrested during a silent protest on January 29 in Port Sudan. According to a witness interviewed by PHR, Dr. Faisal was being targeted for his participation in the protests in el-Obeid in Sudan’s North Kordofan region. NISS forces allegedly made death threats, after which Dr. Faisal fled his home and went to Port Sudan City, where he stayed with friends. The security forces tracked him and two friends down and entered the complex where he was staying. According to the witness, “Dr. Faisal saw the NISS officers in uniform approaching the complex where they were staying. Then he jumped from the balcony of the second floor after security forces fired live ammunition to break the door of the apartment (the team was 10 agents, all of them had guns). He jumped from the second floor in order to save his life and call for help to save the life of his friend, but in vain. He jumped and broke his right leg.”

The witness related that Dr. Faisal sustained a compound leg fracture that was reset at Port Sudan Hospital. He was transferred a few days later to al-Amal Hospital in Khartoum (administered by the NISS), where contacts have confirmed that he has been detained, essentially in solitary confinement, in a dark room with poor ventilation. Dr. Faisal’s medical condition is poor. He cannot move independently and was not provided with any physical therapy or crutches during six weeks of detention. According to the Sudan Doctors’ Syndicate, X-rays repeated at Dr. Faisal’s insistence reveal poor fracture healing. Given his poor nutrition, psychological stress of isolation, and lack of proper treatment, Dr. Faisal’s health deteriorated significantly. He remained in hospital solitary detention until March 15, when a local association reports that he was released from detention.

General Incidents of Intimidation, Persecution, and Violence against Medical Personnel

“When they arrest anyone, they ask what they do. If you say doctor, or if they find out you are … then you are arrested at least for one month. When they get arrested, they usually undergo solitary detention and psychological abuse.”

A Sudanese doctor who witnessed attacks on medical personnel

In addition to corroborating incidents of violence against individual doctors, PHR has verified that Sudanese doctors are being targeted in all facets of their lives and their work. The following incidents indicate the scope of the persecution as well as the resilience of the doctors.

Large-scale AttacksA dormitory housing resident physicians was invaded by the security forces at 10 p.m. on February 22. Some 56 physicians-in-training were arrested by security forces, who entered the building carrying rifles and tear gas. Some of the physicians tried to run away and were injured. Among these, one man fell from a second story balcony and fractured his spine. He was taken to a nearby hospital and treated after his arrest, and was then sent to another town, where his colleagues have not been able to meet with him. A doctor interviewed by PHR confirmed the incident, saying his friend had broken his L2 vertebra. Most of the other doctors were taken to a detention facility and kept overnight without being charged before being released the next day. Witnesses told PHR that “it was terrifying” and that “if they know you are a doctor, they won’t let you alone.”

Extended Detention and TortureFifteen physicians remained in detention at the time of publication. Information on the circumstances of detention or treatment in custody of these physicians is limited, but Sudanese colleagues report that doctors are kept separate from the general population. Reports from Sudanese colleagues also note that physicians are being kept in facilities separate from the other protesters and have been denied any due process or contacts with legal representation or their families. Witnesses report that physicians are specifically abused while in detention and are detained for longer than other protesters: “I know that if a doctor gets arrested, they will be detained for a long time.”

Targeting of PhysiciansWitnesses noted that physicians are specifically targeted during protests, in their homes, and in their places of work. Many doctors said that they do not carry any identification or even a cell phone when they attend protests or go outside. “They may arrest you. A lot of people tell us not to take any identity. I was stopped multiple times. I just say I’m a student.” Another witness noted that “the regime militias and armed forces and police men are focused on doctors. They know that the doctors are contributing a lot to SPA (Sudanese Professionals Association), which is leading the revolutions. When they arrest anyone, they ask what they do. If you say doctor, or if they find out you are [a doctor] from your [identification card], then you are arrested at least for one month. When they get arrested, they usually undergo solitary detention and psychological abuse.” Despite this, many doctors still participate in the protests. One stated that “if I am completely honest, every time I participated, I was terrified that something would happen to me because I’m a doctor. But I didn’t want to be selfish. I wanted to participate because I believed in what’s right for my country.”

Workplace IntimidationPhysicians have also experienced threats, intimidation, and other extreme pressures in their work places. One witness noted that in Khartoum and many other cities, doctors are striking from working in government-run outpatient clinics. However, they still have strong obligations to their communities, so they are seeing their patients in private clinics, hospital wards, offices, and emergency rooms. In response, the government is threatening them with arrest, canceling their opportunity to use their medical work as their military service (Sudan has compulsory military service), and not paying them wages or denying them access to training and education. One witness stated that “a lot of doctors have stopped getting paid.”

These findings indicate that Sudan is violating the basic civil rights of Sudanese physicians, including freedom of expression, freedom of assembly, the right to liberty, and the right to a fair trial. The government is also restricting heath access to people who depend on these medical personnel. Specifically, there is evidence that security forces are:

Targeting doctors involved in the protest movement and those who have voiced support for activists with detention, beatings, intimidation, and, in a few cases, shooting and death;

Carrying out a campaign of persecution and intimidation of medical personnel and other professionals with arbitrary arrests, identification checks, and attacks on facilities and places of residence;

Preventing doctors and other medical personnel from carrying out their duties in medical facilities, their clinics, and their offices by attacking facilities, withholding income, and threatening to renege on obligations to educate and support trainees;

Illegally detaining and torturing medical personnel and preventing due process, access to legal representation, family visitation, or medical care.

The attacks on medical facilities, doctors, and patients represent an egregious violation of human rights when health care is most needed in Sudan. PHR’s analysis of video and clinical images and direct communication with medical colleagues in Sudan make it clear that medical personnel are being deliberately intimidated and persecuted. Importantly, detaining medical personnel has the compounded effect of preventing them from caring for the wounded and sick, thus expanding the impact of these attacks to entire communities. There is also the potential for long-term impact on health facilities that may be contaminated by chemicals from the attacks, eroding the sanctity of medical care and preventing patients from accessing medical care.

“Every time I participated, I was terrified that something would happen to me because I’m a doctor.”

A Sudanese doctor who took part in protests

Torture and Other Abuses

Little is known of the detention conditions of doctors, especially those who have been arrested in the current crisis. However, years of human rights reporting by PHR in Sudan has revealed the extensive use of torture and other human rights violations in Sudan’s prisons and detention centers.[28][29][30][31][32][33][34][35] PHR’s witnesses confirm that physicians are being targeted in this manner: “We have heard details from our colleagues who were released. There is solitary detention and psychological and physical abuse. Doctors are kept in a very dark room where they don’t know the time. Or they are kept in a very cold room with AC on all the time and there is nothing to keep warm. Or one advertisement is played on the channel over and over again without the detainee knowing the time. It is physical and mental torture.”

PHR has assessed several cases of torture and ill-treatment among recent detainees.

One physician was reportedly tortured while in detention, resulting in vision and hearing loss and severe motor disability. He now reportedly requires assistance by the other detainees to stand or walk.

Another physician was undergoing chemotherapy for a malignancy but has been denied any care while in detention, seriously disrupting his treatment plan.

A witness reports that many of his colleagues who were detained have been terrorized by the torture. “One friend got caught December 24 and released one month later. He hasn’t gone again for a protest. He’s very afraid now and very cautious. They destroyed him totally.”

Another witness reported: “I know many people who tell stories of being tortured by electricity, beatings, and mental torture. They are people I know.”

Legal Standards

Sudan’s International Human Rights Obligations

The government of Sudan is a signatory to major human rights treaties, including as a State party to the International Covenant on Civil and Political Rights (ICCPR),[36] the International Covenant on Economic, Social and Cultural Rights (ICESCR),[37] the African Charter on Human and Peoples’ Rights[38] (all since 1986) as well as the Declaration of Alma Ata(1978).[39] As Sudan is a member of the United Nations, all operations of law enforcement officials in Sudan should comply with relevant international standards, including the Code of Conduct for Law Enforcement Officials (General Assembly resolution 34/169)(1979)[40] and the Basic Principles on the Use of Force and Firearms by Law Enforcement Officials (BPUFF) (1990).[41] Furthermore, the Rome Statute of the International Criminal Court includes imprisonment and other severe deprivations of physical liberty (Article 7.1.e), persecution (Article 7.1.h), enforced disappearance of persons (Article7.1.i), and other inhumane acts (Article 7.1.k) as crimes against humanity punishable by the International Criminal Court (ICC).[42] Although Sudan is not formally a party to the Rome Statute establishing the ICC, the Court may have jurisdiction to investigate and prosecute acts that may amount to crimes against humanity under international criminal law.

Sudan’s National Human Rights Obligations

Sudan’s national laws also establish some basic tenets of civil rights but are deeply problematic in allowing broad powers to military and police security forces.[43] The Interim National Constitution (INC) of the Republic of Sudan (2005) sets out fundamental principles protecting human dignity (Article 28), equality (Article 31), due process (Articles 34 and 35), assembly (Article 40), expression (Article 39), and public health (Articles 19 and 46). Importantly, Article 27(3) of the INC makes international treaties to which Sudan is a party an integral part of the Bill of Rights. Sudan’s Criminal Procedure Code (1991) provides for some rights, but there are no adequate custodial safeguards against arbitrary detention and torture.[44] The rights and safeguards enshrined in these documents have not been effectively implemented in practice. Rather, the National Security Act (2010) effectively promotes impunity for the National Intelligence and Security Service by giving immunity from prosecution for all crimes committed by its personnel in the course of their work.[45] Immunity is conditional and can be lifted by the head of security; but there is virtually no practice to that effect. This immunity provision has been repeatedly criticized by human rights treaty bodies. The NSA also does not guarantee the right to legal representation or medical care nor provide for habeas corpus.[29][33] In practice, Sudan’s national legal rights framework actively facilitates human rights violations and protects perpetrators.

Relevant Legal Standards on Use of Force and Protection of Civilian Rights

With regard to the use of force in law enforcement situations, the BPUFF has set out clear guidelines. They require that security forces shall as far as possible apply nonviolent means before resorting to the use of force. Whenever the lawful use of force is unavoidable to protect civilians from violence or other threats to their safety, health, or livelihood, the authorities should use restraint and act in proportion to the seriousness of the offense. Unequivocally, these weapons are not permitted to disperse peaceful protests for political means. Lethal force may only be used when strictly unavoidable to protect life. The BPUFF principles dictate that exceptional circumstances, such as internal political instability or any other public emergency, may not be invoked to justify any departure from the BPUFF. Furthermore, governments shall ensure that arbitrary or abusive use of force and firearms by law enforcement officials is punished as a criminal offense. Sudan’s Interim Constitution guarantees the rights to peaceful assembly and expression (Articles 39 and 40).

Relevant Legal Standards on the Protection of Medical Care

Specifically related to medical care, doctors and other medical personnel have mandatory ethical obligations to prevent illness and care for the sick and wounded, regardless of political affiliation, race, or religion.[46][47] The World Medical Association’s International Code of Medical Ethics and the Medical Ethics Manual describe the duties of physicians, which include administering emergency care and adhering to principles of non-discrimination.[48] Medical personnel have a duty to care for the sick and wounded, both inside medical facilities and outside facilities, when they respond to public emergencies. They must adhere to principles of nondiscrimination in triaging and caring for the sick and wounded.

Governments, in turn, are required to protect health workers’ independence and support their crucial role in civil society to impartially heal the sick and treat the injured. International law dictates that medical facilities and transports, as well as personnel and patients, be free from any infringements on their rights.[49] Specifically, attacks on or interference in the functioning of medical facilities and transports are strictly prohibited. Medical facilities must be protected from violence, attacks, or any other interference with providing their essential functions.[49][50][51] The sick and wounded are, at a minimum, afforded unhindered and nondiscriminatory access to medical care.[51][52] Furthermore, medical personnel are often particularly visible in society, by their dress and equipment and their obligation to care for the sick and wounded, wherever they may be. Governments may not target or punish those who seek to uphold their internationally recognized responsibilities.[51]

These principles are codified in international human rights instruments (including the ICCPR, ICESCR, and the Declaration of Alma Ata), as well as international manuals on health care principles and codes of ethics. While general principles of protection of medical personnel and facilities, set out in Common Article III of the Geneva Conventions, specifically apply to cases of armed conflict, certain minimum provisions apply at all times. Specifically, provisions that “the wounded and sick shall be collected and cared for” and all persons must “be treated humanely, without any adverse distinction founded on race, color, religion or faith, sex, birth or wealth, or any other similar criteria,” must be upheld according to customary international law, even in times of civil or political unrest without explicit armed conflict.[51] Furthermore, Sudan’s Interim Constitution specifically obliges the government to protect health in Article 19: “The State shall promote public health and guarantee equal access and free primary health care to all citizens.”[53] And in Article 46, Sudan obliges the government to affirmatively provide for health: “The State shall promote public health, establish, rehabilitate,[and] develop basic medical and diagnostic institutions, provide free primary health care and emergency services for all citizens.”[53] Certainly, attacking hospitals and making them harmful to the sick and wounded as well as to the hospital staff would be in clear violation of these principles. Violence against unarmed civilians and the targeting of health workers may also be in breach of international criminal law, subject to investigation by the ICC.[42]

Relevant Law on Torture and Cruel, Inhuman, and Degrading Treatment

Torture and other cruel, inhuman, and degrading treatment or punishment violate human dignity and are absolutely prohibited at all times and under all circumstances. Torture is the intentional infliction of severe mental or physical pain or suffering, by or with the acquiescence of state officials. Sudan ratified the ICCPR in 1986.[36] Article 7 of the ICCPR prohibits both torture and cruel, inhuman, or degrading treatment or punishment. The Human Rights Committee established by the ICCPR has affirmed that no derogation is permitted, even in situations of public emergency, and that no justifications, such as those based on orders from a superior officer, can be invoked to excuse violations.[54] Article 10, paragraph 1, of the ICCPR also states that “All persons deprived of their liberty shall be treated with humanity and with respect for the inherent dignity of the human person.”[36]

Furthermore, the UN Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (UNCAT)[55] defines and explicitly prohibits torture and other cruel, inhuman, or degrading treatment. Sudan signed the UNCAT in 1986 but it has yet to ratify it more than 30 years later. As part of international customary law, torture is banned regardless of the explicit ratification of the treaty into Sudanese law. Like the ICCPR, the UNCAT states that these prohibitions are absolute; no emergency or exceptional circumstance can justify their use. In the periodic reviews of its human rights record by the UN Human Rights Council, the Sudanese government has been considering recommendations to ratify the UNCAT. In 2017, the government stated that it was taking steps to do so.

Sudanese national law explicitly bans torture, stating in Article 33 of the Interim National Constitution of the Republic of Sudan (2005) that: “No person shall be subjected to torture or to cruel, inhuman or degrading treatment.”[53]. Of note, Sudanese law left out the term “punishment” to make an exception for Sharia law.

Despite these legal obligations, there is overwhelming evidence that the government of Sudan has been engaging repeatedly in torture.[30][32][35][43][56][57][58][59][60] Over the years, human rights advocates have reported on torture and voiced deep concerns with detention and imprisonment in Sudan, and the UN has highlighted “pervasive” torture and other human rights abuses in Sudan.[29][33][61][62]

Conclusion

“What’s happening in Sudan is a total disaster. There are killings every day. There is no freedom of speech. There is no democracy…. The regime is using all its armed forces to stay in power, and forgetting what’s important, including health and education.”

A Sudanese physician who witnessed attacks on protesters

The findings of this study indicate that the government of Sudan is violating human rights on a massive scale. The National Intelligence and Security Services (NISS) personnel and their adjuncts are using unnecessary and disproportionate force against citizens, targeting medical personnel and facilities, and torturing protesters and medical personnel in detention. Together, these actions violate both national and international laws as well as basic norms of medical ethics and care for the sick and wounded. Despite methodological limitations, these findings provide compelling evidence of ongoing abuses in Sudan.

This study provides evidence that Sudanese security forces have used tear gas, shotgun pellets, and live ammunition to break up peaceful protests and terrorize protesters into leaving the streets. Of note, shotgun pellets are not considered appropriate for crowd control, as they are highly penetrative and indiscriminate and cause significant injury. In 60 cases, as of publication of this report, Sudanese protesters have died as a direct result of what should be safe use of crowd-control weapons. State security forces have beaten and detained hundreds of individuals, both during the protests and in their homes, for speaking out against the government. As one witness stated, “You cannot be safe even inside your home. You cannot imagine what is going on in Sudan unless you live here, it is something very difficult.”

Medical facilities and personnel are both particularly vulnerable and essential during times of social upheaval. They represent a safety net that is obligated to support the community and treat all wounded and sick individuals, regardless of their affiliations; this duty by necessity places medical professionals in the front lines of conflict and human suffering. Physicians and other medical personnel in Sudan have been arrested and detained in the course or exercising their basic civil and human rights: speaking out against government abuse, organizing marches, announcing their willingness to treat all people, and fulfilling their obligations to provide medical care both inside and outside medical facilities. Fifteen of these medical professionals are still detained in unknown conditions. There is concern that Sudan is utilizing a “catch and release” strategy in arresting and detaining medical personnel, abusing them, and then releasing them, only to arrest others. This revolving door of intimidation aims to prevent physicians from participating in the protests or care of protesters, but also serves to decrease vital health care capacity, erode trust in the safety of health institutions, and weaken health systems in the short and long term.

President Omar Hassan Ahmad al-Bashir, the only sitting head of state indicted for war crimes, crimes against humanity, and genocide by the International Criminal Court (in the context of crimes perpetrated in Sudan’s Darfur region), has consistently demonstrated contempt for human rights. For years, evidence of abuses carried out by the security forces, particularly the NISS, at the behest of the president has been reported by numerous human rights groups.[63] Brutal practices of torture, including extreme temperature, solitary confinement, beatings, electric shocking, and psychological torture, are only escalating now. Physicians for Human Rights calls upon President al-Bashir and the Sudanese government to respect the rights and dignity of all Sudanese citizens through an immediate end to both the use of dangerous weapons against protesters and attacks on medical personnel. Sudan must immediately stop its campaign of intimidation, persecution, and torture.

Recommendations

Sudan remains obligated to uphold all human rights treaties to which it is party and to respect the fundamental rights of its citizens. Attacks on its citizens, which erode basic rights and damage health, must stop and those that are responsible must be held accountable.

Physicians for Human Rights calls on the government of Sudan, international bodies, and the United States and other governments to implement the following recommendations without delay:

To President Omar Hassan Ahmad al-Bashir and the Sudanese Government

Immediately cease all attacks on and release both medical personnel and peaceful demonstrators who are being held without charge or trial for exercising their fundamental rights.

Allow medical personnel to freely fulfil their medical obligations and care for their patients irrespective of their or their patients’ political affiliations.

Immediately end torture and ill-treatment of all detainees. Allow for inspections and access to prisoners by families, attorneys, and international observers.

End policies of contempt for and criminalization of basic rights and freedoms, including peaceful assembly and freedom of speech, which have been further restricted in the recent emergency orders.

Prohibit all forms of violence against peaceful protesters and respect United Nations standards for the use of force, which must always be based on the principles of necessity, proportionality (minimum level of force), legality, and accountability, and enforce these laws.

Ensure accountability mechanisms for all those responsible for unnecessary and disproportionate use of force and other human rights violations. Specifically, remove the immunity provisions for the National Intelligence and Security Services in the National Security Act.

Form an independent commission of inquiry to investigate extrajudicial killings and hold all perpetrators of violence against medical personnel and/or facilities accountable according to fair and transparent legal procedures.

Respect and protect the independence and autonomy of the Sudan Doctors’ Syndicate, Central Committee of Sudan Doctors, Sudanese Professionals Association, and other respected independent organizations for their critical contributions to the health and human rights of Sudanese citizens.

Adhere to provisions of Sudanese law that affirm basic human rights principles, including the Bill of Rights of the National Interim Constitution.

Extend an open invitation to all UN Special Procedures/UN Special Rapporteurs to visit the country.

To the United Nations, African Union, Arab League,* Organization of Islamic Cooperation, and European Union

Introduce and support a resolution at the United Nations Human Rights Council addressing the current situation in Sudan related to the protests and subsequent human rights violations.

Identify suppliers of tear gas, lead pellets, and other crowd-control weapons to Sudanese security forces and make concrete efforts to limit export of these weapons until the government of Sudan has ensured adherence to regulations on their use.

Press Sudan to extend an open invitation to the UN Independent Expert on the situation of human rights in the Sudan, the Special Rapporteur on torture and other cruel, inhuman or degrading treatment or punishment, the Special Rapporteur on the situation of human rights defenders, and the Special Rapporteur on the rights to freedom of peaceful assembly and of association.

Pass legislation that would prohibit the export of tear gas or other riot-control items to Sudan until such a time as the Secretary of State certifies that the government of Sudan no longer uses such weapons to repress peaceful dissent.

Appoint and confirm a new U.S. Special Envoy for Sudan and South Sudan (a position vacant since January 2017) to more effectively engage with the Sudanese government to advance the international recommendations outlined above.

Acknowledgements

This report was written by Physicians for Human Rights (PHR) Medical Expert Rohini J. Haar, MD, MPH, research fellow, Human Rights Center, University of California, Berkeley. Contributions to the research and writing were made by PHR staff, including Maryam Al-Khawaja, Europe director, Vincent Iacopino, MD, PhD, senior medical advisor, Michael Payne, advocacy officer, and Susannah Sirkin, MEd, director of policy.

The report benefitted from review by PHR staff, including DeDe Dunevant, director of communications and Donna McKay, executive director.

Research assistance was provided by Makaila Heifner and Sarah Bakir and open-source data verification was provided by Michael Elsanadi, Brian Perlman, Ceren Fitoz, Haley Willis, Jade Wynn, Kavya Nambiar, Lily Greenberg-Call, Mariya Katsman and Tianyi Ding at the Human Rights Center at the University of California, Berkeley School of Law.

This report benefited from review by PHR Board Member Michele Heisler, MD, MPA, professor of internal medicine and health behavior and health education at the University of Michigan medical school and Lutz Oette, PhD, Director of the Centre for Human Rights Law, SOAS, University of London, UK.

The report was edited by Claudia Rader, MS, PHR senior communications manager. It was prepared for publication by Claudia Rader and Theresa McMackin, PHR communications intern.

PHR is especially indebted to our Sudanese physician colleagues, both in Sudan and abroad, who generously gave their time and efforts to this report, and who are unnamed here to protect their safety. We would especially like to thank our colleagues at the Sudanese American Physicians Association for their invaluable advice and guidance.